Inspection on 07/08/08 for Kyffin Taylor House

This inspection was carried out on 7th August 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kyffin Taylor House 19/03/08

Kyffin Taylor House 15/12/06

Kyffin Taylor House 30/01/06

Kyffin Taylor House 24/08/05

Kyffin Taylor House 30/11/04

Kyffin Taylor House 18/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Kyffin Taylor House Deyes Lane Maghull Liverpool Merseyside L31 6DJ Lead Inspector Mrs Trish Thomas Key Unannounced Inspection 7 and 20 August 2008 11:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kyffin Taylor House Address Deyes Lane Maghull Liverpool Merseyside L31 6DJ 0151 527 2822 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Parkhaven Trust Mrs Joan Quinn Care Home 28 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (4) of places Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 The registered person may provide the following category of service only: Care home only - Code PC To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of people who can be accommodated is: 28 Up to 4 people can be accommodated in the category of: Old age, not falling within any other category - Code OP Date of last inspection 19 March 2008 Brief Description of the Service: Kyffin Taylor House is a care home owned by Parkhaven Trust and the manager is Mrs. Joan Quinn. The home is registered for up to twenty-eight older people with dementia. The building has recently been refurbished, providing more bedrooms and en suite facilities, upgraded bathrooms and an extra dining room and lounge. There is a car park at the front of the home and well-maintained gardens at the rear. The weekly charge for this service is £438.70; chiropody and hairdressing are charged for as extras. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that people who use the service receive adequate outcomes. We carried out unannounced visits to Kyffin Taylor on 7 and 20 August 2008. On 7t August, the home was assessed against key national minimum standards. On 20 August a CSCI pharmacist inspector visited to look at the way people’s medication is managed in the home. During out visits, we spoke with residents and staff and looked at records about care, staffing, health & safety and medication. We carried out a tour of the building and grounds. The manager filled in our questionnaire (the Annual Quality Assurance Assessment) and returned it to us before the date of the inspection. This gives us a lot of numerical information about the home, recent improvements, plans for the future and barriers to improvement. What the service does well: What has improved since the last inspection? Kyffin Taylor has been extended and refurbished since the last visit and now provides improved bathing, and communal areas for residents. The rear Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 6 garden is secure and well maintained and there are more parking spaces at the front of the building. What they could do better: When people move into the home, they have had their needs assessed by social workers. Copies of these assessments are provided so the staff at the home will know whether the person’s needs can be met at the home. In some instances, these assessments have not been updated for up to three months. People should only be accepted into the home on the basis of a current assessment of their needs and choices so there is clear up to date information to show their needs can be met there. A visitor whose relative had just moved in to Kyffin Taylor was seen, clearly looking for assistance and staff were slow to give her the help she needed. This was discussed with the manager at a later date and it is recommended that staff be given instruction about their conduct towards visitors in supervision and policy guidance. Pictorial prompts should be placed in key areas, such as bathroom, toilet, bedroom, lounge and dining room doorways. This will help people to get around without asking for help and will increase their independence. To ensure residents are supervised at all times for their safety, it is recommended that one member of staff going off duty gives the handover to the incoming staff, and the remainder of staff continue to support residents, for their safety, until the shift is over. To provide an accurate record of staff employed on each shift, the staff roster should give the full names of staff and their job roles to identify who is providing care and who provides ancillary support. It is recommended that staff wear protective aprons when serving meals to make sure that food is served in hygienic conditions. Residents must be given their medicines as prescribed to make sure their health is not at risk. All records about medicines must be clear and accurate to show that they are being given properly and that all medicines can be accounted for. When people are looking after their own medicines they must be assessed as safe to do so to make sure they are not at risk. Medicines storage should be looked at to make sure staff can access medicines easily when they are needed and ensure residents do not miss vital doses of medicines. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have had their needs assessed before they move in, however some assessments are up to three months old. EVIDENCE: Standard 3. We looked at the care file of a person who was using the respite service and their stay was for a fixed period. This means that a person who has dementia, who lives in their own home, may stay in Kyffin Taylor in times of crisis or to give their carers some free time. The pre-admission social work assessment gave a lot of information about the person’s health and personal care needs, mental health, their mobility and their social preferences. This had last been reviewed by the social worker in June 2008 although the person moved in to Kyffin Taylor in August 2008. The senior member of staff on duty in Kyffin Taylor, said that pre-admission assessments from social services accompanying people using the respite service, may be up to three months old. This could place people at risk if their dependency has increased since the social work assessment was reviewed, and the home is unable to meet their Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 10 needs. The senior person said that staff in the home will review the person’s needs three days after they move in, to make sure staff have up date information on which to base their care plans. It is recommended that staff ensure they have an up to date pre-admission assessment before accepting any person into the home. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are reviewed soon after the person moves in, however the information on which these are based initially, is sometimes out of date. Shortfalls in medication management could pose a risk to the health and welfare of residents. EVIDENCE: Standards 7,8,9 and 10. Care plans for two people were tracked. The outcomes of assessments were checked against their care files and there were action plans in place to guide staff as to how to meet each identified need. For example, for a person who has poor mobility, there was a plan as to how much support they need to get around the home and for bathing. Care plans were supported by risk assessments and reviews, to make sure that people will be safe and their care plans updated, when there is any change in their condition and/or dependency. Because most of the people who live in Kyffin Taylor have been assessed with dementia, there is guidance for staff to follow to meet each person’s emotional/behavioural needs and staff have received training in supporting people who have dementia. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 12 A resident’s daughter said, “I want my mother to stay here permanently. This is a beautiful home and I think she is well looked after.” There are arrangements for people to receive the services of a doctor during their short stay in the home. Those who are living permanently in Kyffin Taylor are registered with local G.P.s and all those living in the home have access to district nurses, specialist dementia services, chiropody and all paramedical and health related services. There were records of people’s medical history on file and guidance for staff to follow in keeping them healthy and ensuring they attend medical appointments or have visits from relevant health professionals. As part of this inspection the pharmacist inspector looked at how the home were handling medicines because there had been two serious incidents of poor medicines management, which had placed residents at risk. We looked at a sample of records regarding medicines together with the medicines to make sure that residents were being given their medicines as prescribed. We also looked at how medicines were stored and disposed of. We saw that medicines storage was very cramped and we found medicines stored in a number of different rooms throughout the building. The medicines were stored safely but the staff giving out medicines sometimes had to gather medicines from the different locations. Records showed that one resident was not given some medicine on two days because the person giving medicines could not find the medicines they needed in the trolley. The records for the receipt of medicines for the residents who were in the home for short periods, for respite care, were very good and could show clearly if medicines were accounted for and were being given to residents as prescribed by the doctor. The records for long-term residents were not as clear and could not show that medicines could be accounted for or that they were being given properly. When we looked at the records which were clear we found that sometimes residents were not given their medicines as prescribed and that some staff signed that they had given the residents their medicines when stock checks showed that they had not been given. When medicines are not given as prescribed residents’ health could be at risk. We also saw that staff did not give medicines according to the printed directions with regard to food. It is important that medicines, which are to be given before or after food, are given at the correct times so that they can work effectively and residents’ health is not placed at risk. The records also showed that not all medicines could be accounted for and if medicines are missing it could place residents at risk. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 13 Some medicines have a limited life once opened and we saw that staff failed to date eye drops when they were opened and it was possible that one resident was being given eye drops, which were out of date. Staff recognised that some residents wanted to look after some of their own medicines, however they failed to check if those residents could do so safely. Staff also failed to check if the residents were continuing to look after their own medicines properly. This poor practice could put residents health at risk from harm. There was no proper system in place for formally verifying respite care residents medication. The manager said that sometimes residents’ medicines had changed before they came into the home but the directions on the boxes that were brought into the home had not reflected this change, this had potentially put these residents at risk. We looked at how medicines were disposed of. Records showed that medicines, which were no longer needed at the end of each month, were recorded properly and returned to the pharmacy for destruction. However medicines, which were refused, were not disposed of correctly and no records were made of their destruction. If medicines are not disposed of properly people’s health could be at risk. For staff guidance there are policies on privacy and confidentiality and people’s care files were kept in a secure area to ensure only those who are authorised, have access to them. Residents of Kyffin Taylor looked well cared for and were spending time as they chose. Obvious attention had been paid to residents’ personal grooming and two people who were asked said their clothing is returned without delay from the in-house laundry. One lady said she was staying for a few weeks in Kyffin Taylor and was keen to go home again. She said staff were very good and kind and she had no complaints, “Everything appears to be running very well.” One person who has lived in the home for a number of years said, “I can’t complain, we have had two moves in the last few months while the building was being done up, and the staff have sorted everything out for us.” Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Kyffin Taylor have the lifestyle they choose and the respite service supports people to remain in their own homes and enables their carers to have a break or holiday. EVIDENCE: Standards 12,13,14,15. There is a programme of activities in Kyffin Taylor. For people who have dementia, it is important that they receive a lot of social support, which is to their liking. For this reason, people’s assessments include records of the things they like to do and a history of their previous employment and the people who are important to them. We spoke with a resident in the garden. He was planting the flowerbeds and said he likes being outside and enjoys gardening. A visitor to the home said that she is always made welcome and she is left in private with her relative without interruptions from staff. However, a visitor whose relative had just moved in was clearly looking for assistance during the visit, and staff were slow to give her the help she needed. This was discussed with the manager at a later date and it is recommended that staff be given Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 15 instruction about their conduct towards visitors in supervision and policy guidance. The service offered by Kyffin Taylor plays an important part in maintaining peoples’ links with the community through respite breaks. This enables them to stay in their own home for as long as possible, with planned periods of residential care when they need it. Residents’ cultural preferences and religion are recorded in their care plans and there are religious services held regularly in the home. People’s diversity is respected through recording their capacity, communication and behavioural support needs and giving staff guidance as to how to support them in the care plans. We went to the kitchen where qualified cooking staff and kitchen domestic assistants are employed. The menus show a variety of choice and alternatives for main meals and a free choice for breakfast and evening meal. The food stores were well stocked with plenty of chilled and frozen foods, fresh fruit and vegetables, and choices of hot or cold drinks and breakfast cereals. There are two dining rooms, both of which are in good decorative order and well furnished, having beautiful views of the gardens. Three people who had just finished their meal were spoken with, one lady said, “The food here is beautiful, nice and hot and they ask us what we want.” Her companions agreed saying, “Very nice.” “Yes I get enough to eat and plenty of drinks.” Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ complaints are listened to and they are protected through safeguarding training and procedures for staff. EVIDENCE: Standards 16 and 18. Kyffin Taylor has a complaints procedure, which is given to people when they move in and is displayed in the home. This means that people (and/or their representatives) know about their right to complain and the time limits and procedures by which their concerns will be investigated. There have been no complaints about Kyffin Taylor since the last visit, however there has been one safeguarding referral regarding a medication error, which has not yet been resolved. Management of Parkhaven Trust followed safeguarding procedures and took action to give staff new medication guidance, intended to avoid future occurrences. CSCI took action by arranging for a CSCI pharmacy inspection, to ensure medication management in Kyffin Taylor meets National Minimum Standards. The outcomes of the pharmacist’s inspection are included in this report under Standard 9. Training records were looked at and these give evidence that sixteen members of staff have received training in Protection of Vulnerable Adults in 2008. This means that staff are trained to know the indicators of abuse and the procedures they should follow where abuse of a residents is suspected. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 17 In this way, people living in Kyffin Taylor will be protected and any concerns about their safety will be investigated by social services and/or police, according to the circumstances. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building is well maintained, hygienic and comfortable however the environment lacks orientation aids to assist people who have dementia to find their way around. EVIDENCE: Standards 19 and 26. The building has recently been extended and refurbished and is clean, bright and comfortable in all areas. One person said she preferred things the way they were, however the majority of people made positive comments, some being the home is, “Beautiful”, “Bright”, “Really lovely,” “Can’t believe it is the same place.” Because people who live in Kyffin Taylor have dementia, it would be helpful to them to have pictorial prompts in key areas, such as bathroom, toilet, bedroom, lounge and dining room doorways. This will help people to get around without asking for help and will increase their independence. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 19 The bathrooms are finished to a very high standard with assisted bathing equipment to support people who are frail, there are also en-suite facilities for residents’ convenience. Domestic staff are employed in Kyffin Taylor, and all areas were maintained to a very good standard of cleanliness during the visit. To ensure they have the relevant skills to keep the home clean and safe, they have received training in infection control and in managing cleaning materials (COSHH). Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well vetted and have the skills they need to support people who have dementia, however, at times there are not enough staff in communal areas to supervise residents, which could place them at risk. EVIDENCE: Standards 27,28,29 and 30. The staff roster was read, this document should give the full names of staff and their job roles to identify who is providing care and who provides ancillary support. Once explained, it was evident that the roster gave a true representation of the staff who were on duty. To support twenty-six residents, there was a shift leader, three care assistants, a cook and kitchen domestic and two general domestic assistants. At handover time care staff going off duty congregated in the area outside the office with their colleagues who were taking over the shift. To ensure residents are supervised at all times for their safety, it is recommended that one member of staff going off duty gives the handover and the remainder of outgoing staff continue to support residents until the shift is over. Over fifty percent of care staff have NVQ qualifications to at least level 2, and one member of staff said she was due to start level 3. The training schedule shows that mandatory and service specific training is provided for staff and those spoken with said they felt that training gives them the skills to support Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 21 people who have dementia. A recently appointed member of staff said she had received induction training and has plenty of support from management. A sample of staff files was looked at and gave evidence of the recruitment and Selection procedures followed. To make sure people are suitable to work in the home, two satisfactory references (if possible from employers) are obtained and CRB and POVA clearances. People fill in application forms, which ask them for their job history, experience, qualifications and personal details. All job applicants are interviewed and on appointment, issued with job descriptions and contracts of employment. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is qualified and experienced and the home is run in the best interests of the people who live there. EVIDENCE: Standards 31,33,35,38. The manager of Kyffin Taylor is Mrs. Joan Quinn. She has a management qualification and many years experience in managing services for people with dementia. Staff said that they receive good support from management and that there is an open door style of management. The views of people who use the service are sought through distributing surveys for them to complete and taking action on their comments. There is a comments and complaints book in the reception area, some of the comments received were, 3/7/08 “Staff always answer the door quickly.” 6/7/08 “Dining Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 23 room is clean and tidy.” 15/7/08 “Home from home, what a lovely atmosphere.” 6/8/08 “It is a lovely home.” Representatives of the registered providers regularly carry out visits to Kyffin Taylor, to make sure people are well cared for and comfortable. Written records of these visits are kept and made available to inspectors. There are records maintained of personal allowances held in safekeeping for some of the residents who request this. This means that they have money to spend as they need it and their money is secure and accounted for. Transactions on each person’s individual records have double signatures of staff managing the transaction, and receipts for purchases are retained as proof of expenditure. The accounts records had last been audited on 17/7/08 and were in order. To ensure the building is safe for people to live and work in, a series of health and safety checks are carried out by staff and qualified engineers. The certificates were seen and were up to date, including those for fire system checks and fire drills. The fire role call is updated with each person’s admission and discharge to ensure that everybody is accounted for in case of fire. A record of accidents to residents and staff is maintained and the accident book is monitored, with action taken to eliminate risks and avoid future occurrences. Four accidents to residents had been recorded for the month of August 2008. There is training and guidance for staff to follow in infection control and the laundry was well organised and clean. Care staff were seen serving meals to residents without wearing protective aprons and it is recommended that they wear protective clothing in future to make sure that food is served in hygienic conditions. Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Records about all aspects of medication must be clear and accurate. They must show that medicines are given properly and that all medicines can be accounted for All medicines must be given as prescribed and both the prescribers’ and manufacturers’ directions are followed to ensure the safety of residents. All medicines must be in date when the are administered If residents look after some or all of their medicines a risk assessment must be in place to ensure it is safe for them to do so. Effective systems must be put in place to ensure it is clearly recorded exactly what medicines each resident is prescribed and this must be verified by a reliable source. Timescale for action 20/08/08 2 OP9 13(2) 20/08/08 3 4 OP9 OP9 13(2) 13(2) 20/08/08 20/08/08 5 OP9 13(2) 20/08/08 Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations To ensure that Kyffin Taylor can meet their needs and they will be properly supported, people should be accepted into the home only on the basis of an up to date assessment of their needs and choices. It is recommended that staff be given instruction about their conduct towards visitors, in supervision and policy guidance. This will mean that people visiting who need assistance will be given the advice they need from staff without delay. It is recommended that pictorial prompts be placed in key areas, such as bathroom, toilet, bedroom, lounge and dining room doorways. This will help people to get around without asking for help and will increase their independence. To ensure residents are supervised at all times for their safety, it is recommended that one member of staff going off duty gives the handover and the remainder of outgoing staff continue to support residents until the shift is over. To provide an accurate record of staff employed on each shift, the staff roster should give the full names of staff and their job roles to identify who is providing care and who provides ancillary support. It is recommended that staff wear protective aprons when serving meals to make sure that food is served in hygienic conditions. 2. OP13 3. OP19 4. OP27 5. OP27 6. OP38 Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North West Region 3rd Floor Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kyffin Taylor House DS0000005416.V365968.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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